Non-verbal signs of pain

[ShayRN]

It always amazes me when I get patients from the hospital who are in horrific pain. I really don't understand. Usually report will include something along the line of "patient is uncooperative with care, hitting, scratching, biting." Then they come rolling in on a gurney and I can hear them screaming from the door to the floor. Do some people not understand when confused little old ladies are in pain they will fight like heck when they are touched. I have driven home crying when I see the sores on some of these people and then find out they were on....Tylenol. COME ON! So with a new season of student graduating, I am going to give you some advice, as a hospice nurse, on non-verbal signs of pain. What we look for when our dying patients cannot tell us they are hurting.

1. Facial grimacing- BIG CLUE, you know that little furrow in the brow?
   
2. Tense body language- If you try to take someone's blood pressure and they are so tense, you can't pull their arm up? Think pain
   
3. Moaning- BIG CLUE
   
4. Them saying- "I hurt everywhere" Another big clue.
   
5. Sleeping all the time. Yes, even if someone sleeps, they could be in pain. I can't STAND when I hear someone say, "Well, they were comfortable because they were sleeping." Guess what? I almost slept through the delivery of my son, had him 18 minutes after I got to the hospital, because I slept when I was in labor. When I hurt, I sleep.
   
6. Combative with care. Think about it. You have someone who is very confused and they are hurting. You are going in to touch them or try to do care. They don't know who you are or what you are doing, all they know is that they hurt and you touching them hurts more. Worse, they can't SAY they hurt because they cannot articulate the sensation with words.
   
7. Elevated respirations/blood pressure/heart rate ALL indicate pain
   

Now, what to do? TREAT. THE. PAIN!!! I cannot say this enough. Be an advocate for your patient. Call the doctor, explain to him I think my patient is in pain. It is 2011 NOBODY deserves to be in pain. If used properly, Morphine is a very effective medication. I can't tell you how many times I have had people come in completely combative and confused, who once pain medication on board, will calm, become clearer and be able to communicate with their families. Many times, I have family members say I can't believe how calm they are, why can't they do this at the hospital? PLEASE, I beg you. You wouldn't let someone having a heart attack go without Nitro or someone with shortness of breath go without breathing treatments would you?

One last thing. Pass the word. Morphine does NOT kill people when given properly. I have given doses of morphine to patients with blood pressures 70/p and they don't die and sometimes when they are comfortable their bodies actually stabilize. Study after study has shown the effectiveness of Morphine and that it does not kill people when given properly, yet that myth persists.

[Esme12, ASN, BSN, RN]

:yeah::yeah::yelclap::yelclap::yelclap:

WELL SAID!!!!

[leslie :-D]

shay, you know i strongly agree with you, but still feel it's a lost cause.

not only is the myth going strong and pervasive, the knowledge deficit is a forerunner as well as fear.

and keep in mind that depression/hopelessness is also r/t pain, and not only their terminal dx.

pts will often deny their pain for whatever reason, and nurse writes "denies pain" without doing an assessment...or, doing an assessment that says otherwise.

a while ago, this ltc facility wanted to have their own hospice within their facility, and i did the inservice.

had to do the inservice on pain, 3x...to no available.

i got feedback that not one pt, got the prn's available to them.

not one nurse felt it necessary, yet the notes told a completely different story.

we can yell til the cows come home, and very few will still believe it.

when i observe nurses looking the other way (STILL telling themselves that THEY won't be the one to kill the pt.), it is at that point i wish the pt to just die.

anything is better, than living in ignored and agonizing pain.

but i do appreciate your shout-out.:hug:

leslie

[dudette10, MSN, RN]

Thank you for your post. I learn a lot here that I hope to take with me when I can finally work as a nurse.

I have a question about confusion + combativeness = pain. Does this apply specifically for hospice patients or can it be any confused + combative patient? I'm thinking about dementia patients and psych patients who are in an acute care setting for reasons other than their primary, chronic diagnosis.

Should a PRN pain med be tried in almost all cases, and if it doesn't work, you at least know it isn't pain and should look for other reasons for the combativeness?

[tyvin, BSN, RN]

Oh how I hear you. In the last LTC facility I worked I was the only one who would give the PRN morphine. As if giving it will turn them into a drug addict. Constantly coming on shift and being told everyone is alright and then finding so and so with resp 64, and the poor soul literally gasping for life ... yes, he is actively dying and has a morphine order for comfort but no one bothers to give it to him; it just slays me.

I got to the point where I would have the docs make the orders routine to ensure that people got the relief. Then I was labeled and I told them all to you know what ...

I could tell many a story of the tragedy and horror I've seen people go through because some nurses don't believe in giving pain medicine. It's against their (insert word) values. They allow built up prejudice to interfere with their practice. I've gotten many a order changed in order to insure a patient's right to pain relief. Many verbal arguments on the merits of giving morphine because the patients will get addicted. Well, that would be nice if 100% of the people I've gotten morphine orders for were not passing on.

I've been trying to figure out how to put in my advanced directives that I only want nurses who aren't prejudiced against giving pain relief. Of course all of them will say they aren't but I've seen too much that contradicts that. Perhaps I will get lucky and go out in a flash which is my wish; who wants to linger ...

When I was a student I was in clinical in the ICU and these two nurses were talking over this man who just had a triple A. One nurse said as she bent over him that he was going down the pipes and the other nurse agreed. I could swear I saw the man react but how could he, he was unconscious. So I decided to take a nonverbal language course.

Wohoooo ... I can't explain how much I learned. I believe that nonverbal language course should be a requirement for every nurse. Anyway, I'm getting off track so Aloha and thank you for your post; a needed and very well written perspective to be sure.

[leslie :-D]

I have a question about confusion + combativeness = pain. Does this apply specifically for hospice patients or can it be any confused + combative patient? I'm thinking about dementia patients and psych patients who are in an acute care setting for reasons other than their primary, chronic diagnosis.

Should a PRN pain med be tried in almost all cases, and if it doesn't work, you at least know it isn't pain and should look for other reasons for the combativeness?

for 1st question, yes, this applies to any type of pt...

whether it is in acute care or anywhere else.

yes, for anyone in pain, i will give whatever analgesia is available.

but if this is new behavior, i will r/o constipation, uri, uti, pain.

iow, it's critical that one seeks the root cause of pain change in ms.

leslie

[classicdame, MSN, EdD]

I totally agree - pain is so misunderstood and not treated effectively. Borderline negligence in my view

[Whispera, MSN, RN]

Confusion + combativeness can also = fear

[DLS_PMHNP, MSN, RN, NP]

I struggle when the occasional hospice pt says "I've hurt a lot of people, I deserve this."

[Pixiesmom, BSN, RN]

Confusion + combativeness can also = fear

It can also = hunger or an episode of incontinence that needs to be addressed.

[thehipcrip]

@ShayRN -- BRAVA!

While on the subject of pain, let's also work to get the word out that:

** there is a BIG difference between addiction to and dependence on pain medication. The former is a psychological and behavioral condition while the latter is a physical one.

** different tools and methods are needed to assess acute and chronic pain;

** it is a myth that people in chronic pain will become addicted if they are treated with narcotics.

[tokmom, BSN, RN]

I struggle when the occasional hospice pt says "I've hurt a lot of people, I deserve this."

That makes me sad.